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40 Cards in this Set

  • Front
  • Back
CHF is a syndrome comprising abnormal left ventricular function and neurohormomal regulation accompanied by which three things
effort intolerance
fluid retention
decreased longevity
what are the four stages of treatment of CHF
1. prevention of heart failure
2. treatment to prolong life
3. treatment to reduce sx
4. end-stage considerations
what are the two major consequences of LV dysfunction
decreased CO
venous congestion
the decreased CO resulting in reduced delivery of oxygenated blood to the vital organs and skeletal muscle is often called...
forward failure
what are the manifestations of forward failure
DEC EXERCISE TOLERANCE
inc fatigue
dec renal perfusion w/ azotemia
cachexia
hypotension
less blood being pumped out of the ventricle resulting in more left behind in the atrium, resulting in increased venous pressure and congestion is called...
backward failure
what else contributes to backward failure
compensatory neurohumoral response- it causes Na/fluid retention
what are manifestations of backward failure
atrial enlargement (-> cause a-fib)
thromboembolism (venous stasis)
edema
dyspnea
hypoxemia
hypoxia
what four independent factors determine left ventricular performance
preload
afterload
contractility
heart rate and rhythm
what is preload
the tension in the ventricle at end diastole
what does excess preload cause
venous congestion- diuretics, nitrates, morphine, Na restriction, water restriction are all effective
What is the traditional mainstay of therapy for those with intractable fluid overload and was shown by the RALES trial to also reduce mortality
loop diuretics like furosemide are traditional

potassium sparing diuretics like spironolactone are also good
what type of drug can reduce excess preload indirectly by improving forward flow through the ventricle
ACEI
or
DIGOXIN
what can excessive diuretic use cause
dehydration -> inadequate preload and forward failure
what is afterload
the wall stress during systole, largely determined by systolic blood pressure
what is the vicious cycle of afterload?
severe hypertension -> chronic excess afterload -> reduced CO -> compensatory neurohumoral response -> increased afterload -> worsened systolic heart function -> reduced CO ...
what can break the vicious afterload cycle by reducing the neurohumoral response and lowering afterload, causing improved cardiac function and less venous congestion
ACEI
what is contractility
the squeezing strength of the pump
what is systolic dysfunction
ejection fraction <45%
What are the most common causes of reduced contractility
MI and idiopathic dilated cardiomyopathy
Name four classes/drugs that directly improve systolic function
DIGOXIN
beta agonists (DA, dobutamine)
phophodiseterase inhibitors
vesnarinone
Why is digoxin the only drug used to directly improve systolic function
the others INC mortality in clinical trials despite improving symptoms
What is the short term and long term effect of beta blockers on contractility
short term reduction
chronic response is INCREASED ejection fraction
What do calcium channel blockers do to contractility
(except amlodipine) they reduce contractility, leading to increased mortality in patients with systolic dysfunction
can abnormally increased contractility cause heart failure
yes- concentric LV hypertrophy; hypertrophic cardiomyopathy
how many CHF patients have a defect in diastolic function
1/3
what is diastolic dysfunction often called
little old lady's heart
What is frequently presribed for diastolic dysfunction
negative inotropes like beta blockers and verapamil
what is the term when excessive afterload reduction causes a situation where the ventricle completely empties at end-systole -> precipitating syncope due to reflex bradycardia (Bezold-Jarisch response) or pulmonary edema due to extreme tachycardia
cavity obliteration
Systolic dysfuction:
dPdT
Ejection fraction
chamber volumes
LV diastolic pressure
etiologies
dPdT- dec dec
Ejection fraction- dec dec
chamber volumes- inc inc
Lv diastolic pressure- inc
etiologies- ischemia, hypertension, idoipathic, toxin (EtOH), infection (chagas)
diastolic dysfunction:
dPdT
Ejection fraction
chamber volumes
LV diastolic pressure
etiologies
dPdT- inc
ejection fraction- inc inc
chamber volumes- dec
LV diastolic pressure- inc
etiologies- hypertension, HOCM
Systolic dysfunction:
ACE inhibitors
CCB
beta blockers
diuretics
digoxin
ACE inhibitors- YES- 1ST LINE
CCB- CONTRAINDICATED (except amlodipine)
beta blockers- ok
diuretics- spironolactone
DIGOXIN- yep
diastolic dysfunction:
ACE inhibitors
CCB
beta blockers
diuretics
digoxin
ACEI- if BP elevated
CCB- verapamil
beta blockers- YES,esp w/ angina
diuretics- beware hypotension
digoxin- CONTRAINDICATED
What do you do for chronic symptomatic bradycardia
pacemaker- there is no drug therapy
What do you do for acute bradycardia
atropine if excess vagal tone is the problem
or
beta agonist- dobutamine, epi
chronic tachycardia reduces cardiac output by limiting __ filling and can eventually cause severe __ dysfunction
diastolic
systolic
what is an underecognizaed cause of CHF
a-fib
what is the drug of choice for maintaining sinus rhythm in heart failure
amiodarone
what can control ventricular rate in a-fib
digoxin
what do you do for patietns with tachycardia that can't be controlled with drugs
surgical ablation of the AV node